Provider Demographics
NPI:1205913902
Name:AJIBOYE, PATRICK (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:AJIBOYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 HIGHWAY 39 N APT 11H
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1075
Mailing Address - Country:US
Mailing Address - Phone:601-693-0118
Mailing Address - Fax:601-553-8175
Practice Address - Street 1:2701 DAVIS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5708
Practice Address - Country:US
Practice Address - Phone:601-693-0118
Practice Address - Fax:601-553-8175
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125514Medicaid
MS00125514Medicaid